Surgical management of goiter with intrathoracic extension at the Philippine General Hospital Department of Otolaryngology Head and Neck Surgery

Objective@#To describe the demographic and clinical characteristics of patients diagnosed with intrathoracic thyroid masses managed surgically in our institution, determine associated factors affecting eventual operative approaches for these patients, and assess postoperative outcomes and complications associated with surgical intervention.@*Methods@#Design: Retrospective descriptive case series. Setting:Tertiary National University Hospital. Participants: 24 patients.@*Results@#The mean age of patients diagnosed with intrathoracic goiters was 55.71 years old, with a 1:1.4 male to female ratio; with most having an intrathoracic extent of Huins Grade 1 (67%) compared to others having Huins Grade 2-3. Majority of patients pre-operatively had a Fine Needle Aspiration (FNA) Bethesda Thyroid Nodule Classification of Category II (benign); 79% of total patients underwent excision of thyroid mass utilizing a transcervical approach alone. As Intrathoracic Extension (ITE) grade increased, additional transthoracic approaches were performed; duration of operation, average estimated blood loss, length of hospital stay was also noted to increase. Majority of post operative surgical histopathology results revealed malignant thyroid masses, in contrast to pre-operative FNA. Post-operative transient hypocalcemia was the most reported immediate complication. @*Conclusions@#Management of intrathoracic goiter is often multidisciplinary. Referral to the thoracic vascular service is warranted for access to the thoracic inlet. Classification by grade of intrathoracic goiters is helpful to determine the most appropriate operative approach and may be predictive of intraoperative and postoperative outcomes. Postoperative histopathology across all ITE grades mostly yield malignant results; hence, preoperative FNA results should be used with caution.

A Bilateral Double Sternalis Muscle in a Korean Cadaver / 체질인류학회지

Although the sternalis muscle has been well known to anatomists, it is quite unfamiliar to clinicians. During routine educational dissection, we came across a well-defined bilateral double sternalis muscle innervated by the intercostal nerve, respectively. The right sternalis muscle 1) became tendinous to insert into the sternum and 2) crossed midline and then intermingled with the left pectoralis major muscle, which could be classified into a double with single cross based on Snosek et al.'s criteria. The left sternalis muscle was composed of two bellies, which were combined at the midway, and became tendinous to insert into the contralateral manubrium, which could be classified into a bicipital diverging with double cross based on Snosek et al.'s criteria. The detailed knowledge on the sternalisis is important for clinicians as well as for anatomists, since the clinical importance of the sternalis muscle has been highlighted in recent years.

Clinical Features of Herniated Disc at Cervicothoracic Junction Level Treated by Anterior Approach

OBJECTIVE: The anterior approach for C7-T1 disc herniation may be challenging because of obstruction by the manubrium and the narrow operative field. This study aimed to investigate the clinical and neurological outcomes of anterior approach for C7-T1 disc herniation. METHODS: We retrospectively evaluated 13 patients who underwent the anterior approach for C7-T1 disc herniation by a single surgeon within a period of 11 years (2003-2014). The minimum follow-up duration was 6 months. We describe the clinical presentation, radiographic findings, neurological outcome, and related complications. RESULTS: Of 372 patients with single-level anterior discectomy and fusion or artificial disc replacement for cervical disc herniation, 13 (3.5%) had C7-T1 disc herniation. The main clinical presentation was unilateral motor weakness in intrinsic hand muscles (11 patients), along with numbness, pain, and tingling sensation that radiate down the arm to the little finger. Most of the patients improved after surgery via the anterior approach. Ten patients underwent successful anterior discectomy and fusion by the standard supramanubrial Smith-Robinson approach, but 2 needed additional manubriotomy and sternotomy. In 1 patient, we performed surgery at a wrong level because the correct level was difficult to identify intraoperatively. Two patients had transient vocal dysfunction, but none had major complications related to injuries of the great vessels such as the thoracic duct or esophagus. CONCLUSION: For patients who require direct anterior decompression for C7-T1 disc herniation, the anterior approach is relatively feasible. However, care should be taken to overcome physical constraints by the manubrium and slope.

Análise do efeito do método Pilates no perfil postural de idosas / Analysis of the effect of Pilates method on the postural profile of elderly women

O processo de envelhecimento é caracterizado por diversas alterações morfológicas, fisiológicas, funcionais e bioquímicas. Objetivos: Investigar o efeito da aplicação de exercícios do método Pilates sobre ângulos e distâncias dos segmentos corporais de idosas. Métodos: Realizou-se um estudo quantitativo, de intervenção, com aplicação de 20 sessões de exercícios do método Pilates, duas vezes por semana, em uma população de 20 idosas, as quais passaram por uma avaliação postural biofotogramétrica pré e pós-intervenção. Resultados: Foram observadas diferenças posturais, constatando-se redução da distância do ângulo inferior da escápula, distância dos epicôndilos, distância do processo estiloide; distância entre T1 e os ângulos inferiores da escápula, diminuição do ângulo manúbrio do esterno e epicôndilos e alinhamento horizontal da cabeça. Conclusões: A prática de exercícios do método Pilates foi suficiente para promover melhora em algumas variáveis posturais. Recomenda-se a realização de novos estudos com população e frequência maiores para obter-se efeito positivo nas demais variáveis do perfil postural.

The aging process is characterized by various morphological, physiological, biochemical, and functional changes. Objectives: To investigate the effect of the application of Pilates exercises on angles and distances of the elderly women's body segments. Methods: We performed an interventional quantitative study consisting of the application of 20 sessions of Pilates exercises twice a week with a population of 20 elderly women who had undergone a postural assessment by biophotogrammetry prior to and following the intervention. Results: We observed postural differences and confirmed a reduction in the distance of the lower angle of the scapula, of the epicondyles, and of the styloid process; a reduction in distance between T1 and the lower angles of the scapula; a reduction in notch angle of the sternum and epicondyles; and horizontal alignment of the head. Conclusions: The practice of Pilates exercises was enough to promote improvement in some postural variables. It is recommended to carry out further studies with larger population and frequency to obtain positive effect on other variables of the postural profile.

Pancoast Syndrome Accompanied by Rotator Cuff Tear

Pancoast syndrome (PS) is characterized by a malignant neoplasm of the superior sulcus of the lung with destructive lesions of the thoracic inlet and involvement of the brachial plexus and cervical sympathetic nerves. The most common initial symptom of PS is shoulder pain; however, cough, dyspnea, and hemoptysis, signs often associated with lung cancer, are not as common. Investigation of PS can be difficult even with plain radiographs of the chest because it is surrounded by osseous structures such as the ribs, vertebral bodies, and manubrium. Due to these characteristics, orthopedic surgeons tend to make a misdiagnosis resulting in delay of appropriate treatment. Here we report on a patient who was supposed to undergo rotator cuff repair for his shoulder pain and weakness, and was eventually diagnosed with PS.

The Transmanubrial Approach for Cervicothoracic Junction Lesions : Feasibility, Limitations, and Advantages

OBJECTIVE: We report on the technical feasibility and limitations of the transmanubrial approach for cervicothoracic junction (CTJ) lesions and emphasize the advantage of bisecting the upper part of the manubrium in an inverted Y-shape. METHODS: Thirteen patients who underwent the fourteen transmanubrial approach for various CTJ lesions were enrolled during 2005-2014. For the evaluation of the accessibility for the CTJ lesion, we analyzed the two parallel line defined as a straight line parallel to the inferior and superior plateau of the upper and lower healthy vertebrae, the angle of the two parallel lines and the distance from the sternal notch to lines at the sternum on preoperative magnetic resonance images. Surgical limitations and perspectives, as well as postoperative clinical outcomes were evaluated retrospectively. RESULTS: The CTJ lesions were six metastases, three primary bone tumors, two herniated discs, and one each of a traumatic dislocation with syrinx formation and tuberculous spondylitis and ossification of the posterior longitudinal ligament. If two parallel lines pass below the sternal notch, the manubriotomy should be inevitably performed. The mean preoperative Visual analogue scale score was 8 (range, 5-10), which improved to 4 (range, 0-6) postoperatively. Seven cases showed an increase in Frankel score postoperatively. CONCLUSION: The spatial relationship between the sternal notch and the two parallel lines to the lesion was rational to determine the feasibility of manubriotomy. The transmanubrial approach for CTJ lesions can achieve favorable clinical outcomes by providing direct decompression of lesion and effective reconstruction.

Pancoast Syndrome Accompanied by Rotator Cuff Tear

Pancoast syndrome (PS) is characterized by a malignant neoplasm of the superior sulcus of the lung with destructive lesions of the thoracic inlet and involvement of the brachial plexus and cervical sympathetic nerves. The most common initial symptom of PS is shoulder pain; however, cough, dyspnea, and hemoptysis, signs often associated with lung cancer, are not as common. Investigation of PS can be difficult even with plain radiographs of the chest because it is surrounded by osseous structures such as the ribs, vertebral bodies, and manubrium. Due to these characteristics, orthopedic surgeons tend to make a misdiagnosis resulting in delay of appropriate treatment. Here we report on a patient who was supposed to undergo rotator cuff repair for his shoulder pain and weakness, and was eventually diagnosed with PS.

Relation between Body Height and Combined Length of Manubrium and Mesosternum of Sternum Measured by CT-VRT in Southwest Han Population / 法医学杂志

OBJECTIVE@#To establish the linear regression equation between body height and combined length of manubrium and mesostenum of sternum measured by CT volume rendering technique (CT-VRT) in southwest Han population.@*METHODS@#One hundred and sixty subjects, including 80 males and 80 females were selected from southwest Han population for routine CT-VRT (reconstruction thickness 1 mm) examination. The lengths of both manubrium and mesosternum were recorded, and the combined length of manubrium and mesosternum was equal to the algebraic sum of them. The sex-specific linear regression equations between the combined length of manubrium and mesosternum and the real body height of each subject were deduced.@*RESULTS@#The sex-specific simple linear regression equations between the combined length of manubrium and mesostenum (x3) and body height (y) were established (male: y = 135.000+2.118 x3 and female: y = 120.790+2.808 x3). Both equations showed statistical significance (P < 0.05) with a 100% predictive accuracy.@*CONCLUSION@#CT-VRT is an effective method for measurement of the index of sternum. The combined length of manubrium and mesosternum from CT-VRT can be used for body height estimation in southwest Han population.

Manubriosternal dislocation with spinal fracture: A rare cause for delayed haemothorax / 中华创伤杂志(英文版)

Type 2 manubriosternal dislocations with concomitant spinal fracture are rare and may be associated with thoracic visceral injuries. The complication of delayed haemothorax has not been reported yet. We report a case of a young male who suffered manubriosternal dislocation with chance type thoracic spine fracture due to fall of a tree branch over his back. The haemothorax presented late on day three. The possible injury mechanism is discussed along with review of literature. We conclude that a lateral chest radiograph is indicated in spinal fracture patients complaining of midsternal pain. Computerized axial tomography scan of chest with contrast is indicated to rule out visceral injuries and a chest radiograph should be repeated before the patient is discharged to look for delayed haemothorax.

Sternal Healing after Coronary Artery Bypass Grafting Using Bilateral Internal Thoracic Arteries: Assessment by Computed Tomography Scan

BACKGROUND: This study aimed to investigate sternal healing over time and the incidence of poor sternal healing in patients undergoing coronary artery bypass graft (CABG) surgery using bilateral internal thoracic arteries. MATERIALS AND METHODS: This study enrolled 197 patients who underwent isolated CABG using skeletonized bilateral internal thoracic arteries (sBITA) from 2006 through 2009. Postoperative computed tomography (CT) angiography was performed on all patients at monthly intervals for three to six months after surgery. In 108 patients, an additional CT study was performed 24 to 48 months after surgery. The axial CT images were used to score sternal fusion at the manubrium, the upper sternum, and the lower sternum. These scores were added to evaluate overall healing: a score of 0 to 1 reflected poor healing, a score of 2 to 4 was defined as fair healing, and a score of 5 to 6 indicated complete healing. Medical records were also retrospectively reviewed to identify perioperative variables associated with poor early sternal healing. RESULTS: Three to six months after surgery, the average total score of sternal healing was 2.07+/-1.52 and 68 patients (34.5%) showed poor healing. Poor healing was most frequently found in the manubrium, which was scored as zero in 72.6% of patients. In multivariate analysis, the factors associated with poor early healing were shorter post-surgery time, older age, diabetes mellitus, and postoperative renal dysfunction. In later CT images, the average sternal healing score improved to 5.88+/-0.38 and complete healing was observed in 98.2% of patients. CONCLUSION: Complete sternal healing takes more than three months after a median sternotomy for CABG using sBITA. Healing is most delayed in the manubrium.

Antropometría del martillo en humanos: un estudio anatómico directo / Anthropometry of the malleus in humans: a direct anatomic study

El conocimiento morfométrico de las estructuras del oído medio, incluidos cada uno de los oscículos, es importante para la comprensión de su complejidad biomecánica. Las características estructurales y dimensionales del martillo son registradas en 23 martillos de población mestiza adulta Colombiana. Las medidas registradas involucran el área de la cabeza, el cuello, el manubrio, el proceso anterior y lateral y el área de la articulación incudo-maleolar. Tres de los diecinueve registros tomados en este estudio pudieron ser comparados concienzudamente con otros estudios que mostraron similitudes. El largo total del martillo fue de 8,18 mm DE 0,24, la longitud del manubrio fue de 4,91 mm DE 0,25 y la proporción del largo del manubrio y el largo total fue de 60,11 % DE 3,47. Conforme a la población estudiada no se logro encontrar variación individual o pareada en la anatomía del martillo lo que lo hace un hueso morfométricamente uniforme y estable.

Morphometric knowledge of middle ear structures, including each of the oscicles, is important for the understanding of its biomechanics complexity. The structural and dimensional characteristics of the malleus are registered in 23 samples of Colombian adult mestizo population. Registered measures involve the area of the head, neck, the manubrium, the anterior and lateral process and the area of the incudo-maleolar joint. Three of nineteen records taken in this study could be carefully compared to other studies, which showed similarities. The total length of the malleus was 8,18 mm SD 0.24, the length of the handle was 4.91 mm SD 0.25 and the ratio of the length of the manubrium and the malleus total length was 60,11% of 3.47. In accordance with the studied population, individual or paired variations were not found in the anatomy of the malleus that makes it a morphometrically uniform and stable bone.

Comparison of two topographical airway length measurements in adults / 대한마취과학회지

BACKGROUND: A correct estimate of the tracheal tube insertion depth can prevent complications, including endobronchial intubation and vocal cord trauma. We evaluated a new topographical method for endotracheal tube positioning relative to the carina, using a well-known prior topographical method for comparison. METHODS: One hundred adult (male 50, female 50) patients were studied. The comparison topographic length (in cm) was measured by adding the distance between the right mouth corner and the right mandibular angle to the distance between the right mandibular angle and the center of the sternal manubrium. The new endotracheal tube insertion depth (in cm) was determined by adding the distance between the right mouth corner and the vocal cords, measured with the endotracheal tube itself, to the distance between the thyroid prominence and the manubriosternal joint, and then subtracting 4 cm. After intubation, the endotracheal tube was positioned properly at the right mouth corner and the endotracheal tube tip was evaluated using a fiberoptic bronchoscope at the carina. RESULTS: The distances from the tip of the endotracheal tube to the carina were not significantly different between the methods in the same gender. However, our method allowed endotracheal tube tip placement between 3 cm and 5 cm, above the carina more frequently than the prior method in males. CONCLUSIONS: The new topographical method can be used as a guide to positioning the endotracheal tubes.

Sternoclavicular Joint Infection: Classification of Resection Defects and Reconstructive Algorithm

BACKGROUND: Aggressive treatment of sternoclavicular joint (SCJ) infection involves systemic antibiotics, surgical drainage and resection if indicated. The purpose of this paper is to describe a classification of post resectional SCJ defects and highlight our reconstructive algorithm. Defects were classified into A, where closure was possible often with the aid of topical negative pressure dressing; B, where parts of the manubrium, calvicular head, and first rib were excised; and C, where both clavicular, first ribs and most of the manubrium were resected. METHODS: Twelve patients (age range, 42 to 72 years) over the last 8 years underwent reconstruction after SCJ infection. There was 1 case of a type A defect, 10 type B defects, and 1 type C defect. Reconstruction was performed using the pectoralis major flap in 6 cases (50%), the latissimus dorsi flap in 4 cases (33%), secondary closure in 1 case and; the latissimus and the rectus flap in 1 case. RESULTS: All wounds healed uneventfully with no flap failure. Nine patients had good shoulder motion. Three patients with extensive clavicular resection had restricted shoulder abduction and were unable to abduct their arm past 90degrees. Internal and external rotation were not affected. CONCLUSIONS: We highlight our reconstructive algorithm which is summarised as follows: for an isolated type B SCJ defect we recommend the ipsilateral pectoralis major muscle for closure. For a type C bilateral defect, we suggest the latissimum dorsi flap. In cases of extensive infection where the thoracoacromial and internal mammary vessels are thrombosed, the pectoralis major and rectus abdominus cannot be used; and the latissimus dorsi flap is chosen.

Lesão oculta da articulação manúbrio-esternal associada à fratura da coluna torácica / Occult manubriosternal joint injury associated with fracture of the thoracic spine

Os autores relatam a ocorrência de lesão oculta da articulação manúbrio-esternal na avaliação inicial de um paciente com fratura da coluna torácica (T9). Foi diagnosticada fratura de T9 no paciente do sexo masculino de 37 anos de idade associada a déficit neurológico parcial. No atendimento inicial, as radiografias realizadas não demonstraram a lesão da articulação manúbrioesternal. Durante a reabilitação, após a estabilização cirúrgica da fratura da coluna torácica, subitamente o paciente sentiu dor intensa, acompanhada de deformidade ao nível do esterno, tendo sido diagnosticada luxação manúbrio-esternal nos exames de imagem. Devido à recidiva da luxação e de dor incapacitante, foi necessária a realização da redução aberta e fixação da articulação manúbrio-esternal. Na avaliação após 12 meses, o paciente apresentou recuperação completa da lesão neurológica, consolidação da artrodese do segmento vertebral T7-T11, e manutenção da redução da articulação manúbrio-esternal, que era assintomática durante a realização das atividades cotidianas.

The authors report the occurrence of an occult manubriosternal joint injury in the initial evaluation on a patient with a thoracic spine fracture (T9). This T9 fracture was diagnosed in a 37-year-old man and was associated with a partial neurological deficit. At the initial evaluation, the radiographs produced did not show the manubriosternal joint injury. During rehabilitation, after surgical stabilization of the thoracic spine fracture, the patient suddenly felt an intense pain accompanied by deformation at the sternal level. From imaging examinations, manubriosternal dislocation was diagnosed. Because of recurrence of the dislocation and the incapacitating pain, open reduction and fixation of the manubriosternal joint had to be performed. At the 12-month follow-up, the patient presented complete recovery of the neurological lesion, consolidation of the arthrodesis on the T7-T11 vertebral segment and maintenance of the reduction of the manubriosternal joint, which was asymptomatic during daily activities.

Shall We Resect the Tip of Manubrium Mallei in Tympanoplasty?

OBJECTIVES: In tympanoplasty operations if perforation is related with malleus handle, malleus handle is desepithelised. We planned this research to investigate whether the epithelial remnants remain as a result of this desepithelisation or not. METHODS: The 35 patients who were performed tympanoplasty operation were divided into two groups. In the first group which included 13 patients the tip portion of manubrium mallei were cut off without desepithelisation. In the second group which included 22 patients the tip portions of manubrium mallei were cut off after the meticulous desepithelisation. The presence of squamous epithelium was examined histopathologically on the specimens. RESULTS: Squamous epithelium was observed in 9 of the 13 non-desepithelised specimens and in 6 of 22 desepithelised specimens. CONCLUSION: In tympanoplasty operations despite careful desepithelisation, squamous epithelial remnants may remain on the malleus handle. So the tip of manubrium mallei could be resected to prevent the future development of cholesteatoma.

Shall We Resect the Tip of Manubrium Mallei in Tympanoplasty?

OBJECTIVES: In tympanoplasty operations if perforation is related with malleus handle, malleus handle is desepithelised. We planned this research to investigate whether the epithelial remnants remain as a result of this desepithelisation or not. METHODS: The 35 patients who were performed tympanoplasty operation were divided into two groups. In the first group which included 13 patients the tip portion of manubrium mallei were cut off without desepithelisation. In the second group which included 22 patients the tip portions of manubrium mallei were cut off after the meticulous desepithelisation. The presence of squamous epithelium was examined histopathologically on the specimens. RESULTS: Squamous epithelium was observed in 9 of the 13 non-desepithelised specimens and in 6 of 22 desepithelised specimens. CONCLUSION: In tympanoplasty operations despite careful desepithelisation, squamous epithelial remnants may remain on the malleus handle. So the tip of manubrium mallei could be resected to prevent the future development of cholesteatoma.

Alternativas quirúrgicas en el tratamiento de los tumores: de la pared torácica / Surgical alternative for the treatment of thoracic wall tumor

Los tumores de la pared torácica son neoplasias poco frecuentes, y de difícil tratamiento. Cuatro pacientes con neoplasias de la pared torácica fueron intervenidos en el Hospital Universitario de Maracaibo entre los años 2005 a 2008, con los diagnósticos de: plasmocitoma en dos pacientes y condrosarcoma en dos pacientes. Entre las intervenciones quirúrgicas realizadas destacan: resección de tumor de la pared torácica e interposición de malla en tres pacientes y resección de tumor esternal con interposición de malla y metacrilato en un paciente. La evolución posoperatoria fue satisfactoria en tres pacientes, un paciente en quien se interpuso malla y metacrilato se produjo el desplazamiento de la malla a un año de la intervención. Es importante en los pacientes con tumores de la pared torácica una adecuada planificación preoperatoria de la intervención para disminuir la morbilidad y mortalidad posoperatoria, y lograr mejores resultados quirúrgicos y funcionales.

The chest wall tumors are neoplasm with a low frequency and they are of difficult in the treatment. Four patients with chest wall neoplasm were operated in the Universitary Hospital from Maracaibo between 2005 at 2008 with the diagnoses of plasmacytoma in two patients and chondrosarcoma in two patients. The surgical procedures for us performed were: Chest wall tumor resection and mesh interposition in three patients and sternum tumor resection with interposition of mesh with methyl methacrylate in one patient. The postoperatory evolution was satisfactory in three patients and the patient with the reconstruction using mesh and methyl methacrylate had the displacement of the mesh after of a year of the surgical procedure. It is very important in the patients with chest wall tumors an adequate preoperatory evaluation with the objective of reduces the mortality and morbidity postoperatory and obtains better surgical and functional results.

Estimation of age in the living municipal employees in the age group of 25-45 years by physical and radiological examination.

Employees from government and local self-government bodies come to Departments of Forensic Medicine for age estimation for the purpose of permanent employment. According to the rules and regulations of the Municipal Corporation of Greater Mumbai (MCGM) and court orders, they are confirmed as permanent employees after a specified duration of temporary service. The age criterion is very important as regards their dates of retirement and service benefits. But because of low socioeconomic status & illiteracy, most of these employees have no documentary evidence of their birth dates. Their age, therefore, remains a mystery to be solved. The human body develops very fast in the first 20 years of life, but growth slows thereafter. There is precious little information on the estimation of age in the later years, resulting in the lack of reliable methods for this purpose. A sincere attempt to arrive at a fairly conclusive range of age with respect to changes in physical features, especially graying of hair, wrinkling of skin and radiological evaluations of fusion of components of the sternum and changes in the teeth and mandible with respect to mandibular canal seen in an oral orthopantomogram was contemplated.

Myxofibrosarcoma of the Chest Wall / 대한흉부외과학회지

Myxofibrosarcoma is one of the most common soft tissue tumors in elderly patients, mostly arising in the extremities, and rarely arising in the chest wall. A 53-year-old women presented with a painful chest wall mass in the manubrium. We excised the mass. The mass was located subdermally, but had infiltrated the underlying muscle layer, and was histologically diagnosed as an intermediate grade myxofibrosarcoma showing myxoid changes and hypercellularity. Here we report a rare case of chest wall myxofibrosarcoma and present a review of the literature.

Aortic Arch Rupture due to Compression Injury of the Thorax: A case report / 대한흉부외과학회지

Traumatic rupture of the thoracic aorta is the second most common cause of death from motor vehicle accidents after head injury. About 85% of these patients do not survive to reach the hospital. The most common mechanism for this is deceleration injury, as occurs in a high speed motor vehicle accident. The aortic isthmus is the site of disruption for about 95% of all blunt thoracic aortic injuries. Another mechanism is crush injury which causes compression of the aorta between the displaced sternal body or manubrium and the thoracic vertebral column. These forces tear the inner layer of the aortic wall at an unusual location. We report here on a case of aortic arch dissection where the injury clearly occurred due to a crush injury and not because of deceleration. The surgical repair was delayed for 10 days after administering intensive medical therapy. The ascending aorta and aortic arch were replaced with an artificial graft with the patient under circulatory arrest and cerebral protection.